Sarcopenia and Sarcopenic Obesity in Patients Undergoing Orthopedic Surgery

Psoas muscle area is associated with prognosis in elderly patients with hip fracture

INTRODUCTION

Sarcopenia is a key predictor of prognosis in patients with hip fractures. This study utilized computed tomography (CT) scan (1) to determine the association between psoas muscle cross-sectional area (CSA) and mortality, along with other muscles, and (2) to confirm the correlation between muscle CSA and appendicular lean mass (ALM) measured using DXA in elderly patients with hip fracture.

MATERIALS AND METHODS

Patients who were aged ≥ 50 years and underwent surgical treatment for hip fracture were eligible for this study. After a series of exclusion criteria, 217 female patients were included. Patient data, including clinical characteristics, such as body mass index (BMI), CSA, and ALM, were retrospectively collected. The Kaplan-Meier survival method and Cox proportional hazards regression analysis were used for the statistical analyses. The correlation between CSA/BMI and ALM was also assessed.

RESULTS

Patients in the lowest quartile of psoas muscle CSA/BMI had shorter survival times than those in the other quartiles. When the Cox proportional hazards regression analysis was adjusted for multiple variables, the lowest quartile of the CSA/BMI of the psoas was a risk factor for mortality. The CSA/BMI of the psoas showed the highest correlation coefficient. The CSA/BMI ratio of the other muscles showed a moderately positive correlation with ALM.

CONCLUSION

The CSA of the psoas is associated with prognosis in elderly patients with hip fractures and shows a moderately positive correlation with ALM. Hence, the CSA of psoas is useful for predicting survival and muscle mass in elderly patients with hip fractures.

Relationship between the preoperative grip strength and postoperative shoulder strength of patients treated via reverse shoulder arthroplasty

BACKGROUND

Systemic disorders including diabetes mellitus, obesity, and depression affect the outcomes of reverse shoulder arthroplasty (RSA). Sarcopenia (a general skeletal muscle disorder) is common in elderly people, but its effect on patients after RSA is not clear. We hypothesized that the preoperative sarcopenia indices of grip strength and general skeletal muscle mass would correlate with the clinical outcomes of RSA.

METHODS

Grip strength and general skeletal muscle mass were measured in patients scheduled (between 2016 and 2021) for primary RSA to treat cuff tear arthropathy, an unrepairable cuff tear, or osteoarthritis with a large cuff tear. Before surgery, grip strength was measured using a hydraulic dynamometer and general skeletal muscle mass was calculated from the appendicular relative skeletal muscle mass index (aRSMI) using dual-energy X-ray absorptiometry. In all, 58 patients were included; the minimal follow-up duration was 12 months. The postoperative clinical results (pain, active range of motion, shoulder strength, and functional scores) were evaluated during scheduled outpatient visits. We calculated correlations between the preoperative sarcopenia indices, and the clinical results at the final follow-up.

RESULTS

The mean preoperative grip strength and aRSMI were 21.6 ± 4.0 kg and 5.98 ± 0.84 kg/m2 in females and 30.6 ± 7.5 kg and 7.21 ± 0.94 kg/m2 in males, respectively; the grip strength and aRSMI were not associated with each other (P = .083). Ten females (25%) and 10 males (56%) met the criteria for sarcopenia. The postoperative abduction shoulder strength and Constant-Murley shoulder score increased significantly with higher preoperative grip strength (R = 0.420 and P = .001; and R = 0.497 and P < .001, respectively) and the American Shoulder and Elbow Surgeons score was related to the preoperative aRSMI (R = 0.320, P = .039).

CONCLUSIONS

The shoulder strength and functional score after RSA correlated positively with the preoperative grip strength. Measuring grip strength before RSA allows the surgeon to predict shoulder strength after RSA.

[Nutritional, bone and body composition assessment of patients with knee and hip arthroplasty]

INTRODUCTION

malnutrition, both due to deficiency and excess of nutrients, is related to the morbidity of the surgical patient.

OBJECTIVES

to analyze the nutritional status, body composition and bone health of patients undergoing elective knee and hip arthroplasty.

METHODS

an observational cross-sectional study was carried out evaluating patients undergoing hip and knee replacement surgery from February to September 2019. The Malnutrition Universal Screening Tool (MUST), anthropometry, hand-grip dynamometry, bone densitometry, lumbar spine X-ray and bioimpedance analysis were performed.

RESULTS

eighty-six patients (61.6 % women) were evaluated, with a mean age of 69.5 ± 9.5 years. The mean body mass index (BMI) was 31.3 ± 4.5. According to MUST, 21.3 % were at risk of malnutrition; 16.9 % had decreased triceps skinfold with respect to p50 and 20 % had a pathological hand-grip dynamometry. In 91.4 %, vitamin D was < 30 pg/ml. In the bioimpedanciometry, the women presented significantly decreased muscle mass values. Age was correlated with a lower presence of fat-free mass, total and appendicular muscle mass. In those over 65 years of age, 52.6 % of men vs 14.3 % of women had a decreased muscle mass index; 58.5 % had low bone mineral density. We observed vertebral bone collapses in 13.9 %.

CONCLUSION

there is a high prevalence of obesity in patients who are candidates for arthroplasty and this does not exclude the existence of a risk of malnutrition. They may also have decreased muscle mass and strength. Nutritional education and physical exercise recommendations are essential in order to optimize nutritional status for surgery.

Prevalence of Sarcopenic Obesity in Various Comorbidities, Diagnostic Markers, and Therapeutic Approaches: A Review

The coexistence of sarcopenia and obesity characterizes sarcopenic obesity. In this condition, there is an imbalance between lean and fat mass amounts. It is a prevalent issue that is gaining prevalence among the elderly population. To evaluate the condition, allied health professionals may employ non-invasive diagnostic techniques, such as gait speed, skeletal muscle mass, and muscle strength. Nevertheless, early diagnosis and treatment of pathology are essential for preventing debilitating effects and providing the highest quality of care. This article reviews the prevalence of sarcopenic obesity in numerous medical conditions, such as cancer, arthritis, postoperative cases, diabetes mellitus, obesity, and metabolic syndrome. In addition, this paper aims to examine the available evidence regarding the prevalence of sarcopenic obesity in other conditions along with their diagnostic markers and therapeutic approaches.

Identification of sarcopenic obesity in adults undergoing orthopaedic surgery: Relationship between “a body shape index” (ABSI) and fat-free mass. A cross -sectional study

Background

Sarcopenic obesity is a condition characterised by the coexistence of low muscle mass and function (sarcopenia) and excessive fat mass (obesity). The aim of this study was to determine the prevalence of this condition in patients undergoing orthopaedic surgery by gender and type of orthopaedic surgery. In addition, this study investigated the suitability of a waist circumference-based anthropometric measure, body shape index (ABSI), for predicting sarcopenic obesity and the predictive power of ABSI for fat-free mass index (FFMI), a surrogate marker of lean body mass.

Methods and findings

A cross-sectional study of overweight and obese orthopaedic patients undergoing knee or hip and spine surgery was conducted between October 2019 and March 2020 in Orthopaedic Hospital Valdoltra, Slovenia. General anthropometric parameters body mass index (BMI) and ABSI = (WC/(BMI^2/3x height^½) as well as body composition data (fat mass FM, fat-free mass FFM, FFMI, and the ratio FM/FFM as an index of sarcopenic obesity) were determined in 120 women (aged 66.5 ± 9.6 years) and 89 men (aged 65.5 ± 7.8 years) with overweight (25 kg/m² ≤ BMI < 30 kg/m²) and obesity (BMI ≥ 30 kg/m²) by bioelectrical impedance analysis (BIA). Sarcopenic obesity phenotypes based on FM/FFM ratio > 0.80 was present in 15.3% of patients, mainly in female patients undergoing knee surgery. ABSI was significantly associated with age in all women and obese men and with waist circumference (WC) in all patients. ABSI did not correlate with BMI in women and men; however, multiple linear regression analysis showed that BMI independently predicted FFMI (R = 0.83 and 0.70, respectively, p < 0.001) in women and men (β-coefficients: 0.801 and 0.686, respectively) and ABSI in women only (β-coefficient: -0.104). Women with a lower ABSI had a significantly higher FFMI than the group with a higher ABSI.

Conclusions

Sarcopenic obesity was most prevalent in obese women scheduled for knee surgery. In addition, ABSI, independently predicted FFMI in women and represents a significant predictor of sarcopenic obesity.

Sarcopenia, Ectopic Fat Infiltration Into the Lumbar Paravertebral Muscles, and Lumbo-Pelvic Deformity in Older Adults Undergoing Lumbar Surgery

STUDY DESIGN

A retrospective analysis of a prospective, non-randomized cohort dataset.

OBJECTIVE

To cross-sectionally examine the prevalence of sarcopenia and the association between spine-pelvic deformity and skeletal muscle volume loss and ectopic fat infiltration into lumbar paravertebral muscles (PVMs) in patients who underwent lumbar surgery.

SUMMARY OF BACKGROUND DATA

Muscle quality deterioration has been considered the main pathology of sarcopenia, reducing muscle strength directly. The qualitative deterioration as well as volume loss in PVM, which contributes significantly to core body extension, might cause aging-related spine deformity.

METHODS

In total, 184 patients were included. Sarcopenia was diagnosed at baseline, and all patients underwent whole-body X-ray. The amount of fat in lumbar PVM was evaluated with the Goutallier classification in magnetic resonance imaging findings. The expression of adipogenesis- and atrophy-promoting factors in PVM was evaluated with quantitative polymerase chain reaction.

RESULTS

In total, 36.1% of adults aged ≥60 years were diagnosed with sarcopenia. The values of skeletal muscle indexes of the limb and trunk were inversely correlated with the sagittal vertical axis, pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL) values. The PT and PI-LL were greater, PVM area was smaller, and Goutallier grade was greater in sarcopenic adults than in non-sarcopenic older adults. Additionally, the PVM area correlated with the LL value, and Goutallier's grade correlated with the PT and PI-LL values. Moreover, the amount of ectopic fat in PVMs inversely correlated with skeletal muscle indexes. The expression levels of atrophy gene-1 and muscle ring-finger protein-1 did not differ between the groups and did not correlate with the PVM area. In contrast, the expression of Pparg and Cebpa was upregulated in sarcopenic older adults, where it correlated with Goutallier's grade.

CONCLUSION

The volume loss of skeletal muscle, including lumbar PVM, and ectopic fat infiltration into the PVM, may cause the lumbo-pelvic deformity.Level of Evidence: 3.

Nutritional and Physical Prehabilitation in Elective Orthopedic Surgery: Rationale and Proposal for Implementation

In the past, good food and exercise were not considered effective interventions to promote recovery in orthopedic surgery, and prolonged bed rest with not many calories has been deemed sufficient for the proper health restoration until the end of the nineteenth century. The advancement of scientific knowledge proved just the opposite, thus pushing health professionals to sustain the nutritional status and physical fitness of surgical patients. Nevertheless, the impoverishment of lifestyles and the lengthening of life expectancy have invariably contrasted the strength of constitution, giving rise to two of the most hazardous conditions for orthopedic patients: malnutrition and sarcopenia, often hiding nutrient deficits and poor body composition. These conditions are known to be negative prognostic factors in several areas of major surgery, including hip replacement, knee replacement, and spine surgery. Scoring systems to screen for malnutrition and physical inabilities exist, but disciplined management of the derived risks remains untested, potentially hindering the implementation of research findings into practice. A methodical approach of preoperative analysis, critical monitoring, and risk correction before surgery could lead to a substantial improvement of the prognosis while warranting the safety of patients and the efficiency of enhanced recovery after surgery pathways. The aim of this article is to discuss from a dietetic and exercise perspective the ideal nutritional and physical prehabilitation to lay the foundations for designing the appropriate integration of dietitians and physiotherapists in a preoperative enhanced recovery pathway. This methodical analysis could effectively calculate the patient’s risks, detect the best choices for resolving the risk, underline the ignored aspects of perioperative care, and represent a concrete means to integrate novel discoveries.

Body Composition Changes in the Immediate Peri-operative Period Following Total Joint Arthroplasty

BACKGROUND

Bioimpedance analysis (BIA) is a readily available tool to assess body composition in a clinical setting. BIA has received little attention in orthopaedics and namely joint arthroplasty. This study aims to quantify changes in body composition in the immediate peri-operative period following total joint arthroplasty.

METHODS

Adults scheduled for elective total joint arthroplasty were recruited to participate. Patients underwent BIA scans in the immediate peri-operative period: pre-operative on their day of surgery, post-operative day 0, and post-operative day 1.

RESULTS

67 patients were enrolled to undergo BIA scans. Mean age was 62.64 ± 10.28 years old, and 49.2% were females. The all-supine cohort exhibited a 0.36 ± 0.61 kg increase in dry lean mass (p < 0.001) and 1.30 ± 2.14 kg increase in lean body mass on postoperative day 0 (p < 0.001). Patients received to 1.16 ± 0.58 kg of fluid mass, on average.

CONCLUSION

BIA is a rapid, portable tool that allows for body composition analysis of an inpatient surgical population. This study demonstrated that BIA can detect net fluid changes and may approximate implant mass following total joint arthroplasty. This may aid surgeons in interpreting post-operative body composition changes.

Is sarcopenia a risk factor for rotator cuff tears?

BACKGROUND

Sarcopenia is the loss of muscle mass and consequent loss of muscle function with aging. Currently, it is considered an independent risk factor for falls and fractures, disability, postoperative complications, and mortality. Rotator cuff tears are known to be influenced by systemic diseases such as diabetes mellitus, hypercholesterolemia, thyroid disease, and osteoporosis. The aim of our study was to determine if there is a correlation between sarcopenia prevalence and rotator cuff tears.

METHODS

This is a prospective case-control study. Between May 2017 and May 2018, 106 patients were evaluated and divided into 2 groups. Group 1 (cases) included 53 consecutive patients with chronic symptomatic full-thickness rotator cuff tears (mean age, 72 ± 5 years), and group 2 (controls) included 53 patients without rotator cuff tears (mean age, 71 ± 6 years). Sarcopenia was diagnosed with the presence of 2 of 3 criteria: low skeletal muscle mass, inadequate muscle strength, and inadequate physical performance. Rotator cuff integrity was evaluated with magnetic resonance imaging in all patients.

RESULTS

No significant differences were found in baseline data and demographic factors between the groups, except for the smoking habit (P = .02). The prevalence of sarcopenia was not significantly different between the groups, nor were gait speed, grip strength, and skeletal muscle mass index (P = .15, .99, and .9, respectively).

CONCLUSION

The prevalence of sarcopenia in patients with rotator cuff tears was similar to an age- and sex-matched control population. Thus, with these results, we are not able to consider sarcopenia as an independent risk factor for rotator cuff tears.

A Novel Technique for Radiographic Diagnosis of Sarcopenia that Accurately Predicts Postoperative Complications in Lower Extremity Free Flap Patients

INTRODUCTION

 Sarcopenia is linked to poor outcomes throughout the surgical literature and can be assessed on preoperative imaging to potentially aid in risk stratification. This study examined the effects of sarcopenia on surgical morbidity following lower extremity (LE) reconstruction, and also compared two methods of assessment, one of which is novel ("ellipse method").

METHODS

 A retrospective cohort study of 50 patients receiving free flap-based reconstruction of the LE was performed. Bilateral psoas density and area were quantified at L4 through tracing ("traditional method") and encircling ("ellipse method") to calculate Hounsfield unit average calculation (HUAC). Logistic regression and receiving operator curve analysis for the primary outcome of any postoperative complication was used to determine HUAC cutoffs (≤ 20.7 vs. ≤ 20.6) for sarcopenia. Risk of complications associated with sarcopenia was evaluated using Fisher's exact tests.

RESULTS

 Twelve patients (24%) met criteria for sarcopenia via the traditional method and 16 (32%) via the ellipse method. By both methods, sarcopenic patients were older and more often female and diabetic. These patients also had higher American Society of Anesthesiologists scores and lower serum prealbumin levels. The ellipse method was found to be more accurate, sensitive, and specific than the traditional method in predicting postoperative morbidity (p = 0.009). Via the ellipse method, sarcopenic patients were at higher risk for any complication (p = 0.002) and were at a higher risk for a deep vein thrombus or pulmonary embolism via the traditional method (p = 0.047).

CONCLUSION

 Sarcopenia is associated with greater pre- and postoperative morbidity in LE reconstruction. The novel ellipse method is a simplified and accurate method of assessing sarcopenia that can be easily performed in the clinical setting.

Impact of appendicular and trunk skeletal muscle mass and back extensor strength on sagittal spinal alignment in Japanese women without vertebral fracture

Objectives

Progressive and generalized loss of skeletal muscle mass (SMM) and strength are characteristics of sarcopenia. However, the impact of appendicular and trunk SMM and back extensor strength (BES) on spinal sagittal alignment remains unclear. Herein, we investigate the relationship between these factors and spinal sagittal alignment.

Methods

In total, 202 women without vertebral fractures (median age, 66.9 years; interquartile range, 61.4–71.9 years) were analyzed at an orthopedic outpatient clinic. Pelvic incidence (PI), lumbar lordosis (LL), sagittal vertical axis (SVA), and pelvic tilt (PT) were measured on whole spine radiographs. Body mass index (BMI), appendicular and trunk relative SMM index, and BES were also evaluated. These measurements were compared between spinal sagittal alignment groups using the Mann–Whitney U test. Finally, the factors contributing to abnormal alignment were analyzed using multiple logistic regression analysis.

Results

BES was significantly lower in all abnormal sagittal alignment groups, as defined by PI-LL (≥ 10°), SVA (≥4 cm), and PT (≥20°) (all P < 0.001). On multivariate analysis, BES was a contributing factor for abnormal PI-LL (P < 0.001), SVA (P = 0.001), and PT (P < 0.001). Conversely, a decrease in appendicular and trunk relative SMM index did not statistically affect abnormal spinal sagittal alignment.

Conclusions

BES was associated with changes in spinal sagittal alignment; however, SMM, which is often used for diagnosing sarcopenia, did not affect spinal sagittal alignment.

Identifying Patients with Osteoarthritis at Risk of Sarcopenia using the SARC-F

Background

Sarcopenia is an important modifiable risk factor in patients being considered for elective knee or hip replacement as it may be associated with a higher risk of post-operative joint replacement complications. Our objectives are to determine the prevalence of patients with osteoarthritis at risk of sarcopenia by using the SARC-F tool, and whether risk of sarcopenia is associated with referral to an orthopaedic surgeon.

Methods

We conducted a retrospective review of patients who were 60 years or older assessed at four Canadian musculoskeletal assessment centres. Patients completed the SARC-F as part of their assessment. Multivariable logistic regression analyses were conducted to determine association between risk of sarcopenia and the odds of referral to an orthopedic surgeon for surgical consultation.

Results

3,697 patients were included and 67.8% (2,508/3,697) were at risk of sarcopenia. Prevalence was highest in those assessed for hip replacement at 72.3% (635/878). Patients at risk of sarcopenia were more likely to be referred to an orthopaedic surgeon (OR 1.299; SD 1.074–1.571).

Conclusions

Patients with osteoarthritis assessed for joint replacement are at high risk of sarcopenia, particularly individuals undergoing potential hip replacement. Patients at risk of sarcopenia are more likely to be referred to orthopaedic surgery for surgical consultation.

Associations Between Self-Reported Weight History and Sarcopenic Obesity in Adults with Knee Osteoarthritis

OBJECTIVE

The purpose of this study was to examine associations between self-reported weight history and sarcopenic obesity in adults with advanced knee osteoarthritis (OA).

METHODS

Self-reported weight history was collected from n = 151 adults (58.9% female) with knee OA and BMI ≥30 kg/m² in a cross-sectional study. Body composition was assessed using dual-energy x-ray absorptiometry. Sarcopenic obesity was defined as appendicular skeletal muscle mass, adjusted by BMI, <0.51 kg/m² in females and <0.79 kg/m² in males; prevalence was 27.2%. Weight gain in the preceding year, weight gain ≥5% of body weight in the past decade, and multiple weight cycling events in life-span (loss of ≥10 lb [4.5 kg] with regain ≥3 times) were examined using logistic regression (adjusted by age, sex, and %fat mass), with the dependent variable of sarcopenic obesity presence.

RESULTS

Weight gain in the preceding year was associated with sarcopenic obesity (odds ratio [OR]: 2.45, 95% CI: 1.02-5.87). No associations were found with weight gain in the past decade (OR: 1.04, 95% CI: 0.43-2.5) or weight cycling (OR: 0.86, 95% CI: 0.37-2.01).

CONCLUSIONS

In adults with obesity and advanced knee OA, self-reported weight gain in the preceding year was associated with sarcopenic obesity. This patient population may benefit from recommendations that prioritize prevention of weight gain.

Hand grip strength can predict clinical outcomes and risk of falls after decompression and instrumented posterolateral fusion for lumbar spinal stenosis

BACKGROUND CONTEXT

There has been limited research on the association between hand grip strength (HGS) as one of the diagnostic criteria for sarcopenia and surgical outcomes of lumbar spinal stenosis (LSS).

PURPOSE

We aimed to determine the effect of HGS on surgical outcomes and risk of fall in patients with LSS.

STUDY DESIGN

This is a retrospective observational study.

PATIENT SAMPLE

We included 200 patients who underwent spinal surgery for LSS.

OUTCOME MEASURES

We recorded clinical outcome parameters, including Oswestry Disability Index (ODI), Euro-QOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain. To assess the risk of fall we used HGS and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, sit-to-stand test).

MATERIALS AND METHODS

ODI, EQ-5D, and VAS scores for back and leg pain were assessed preoperatively and 1 year after surgery. The four functional mobility tests were assessed at each time point during the 1-year follow-up period to assess the risk of fall in patients with LSS. We divided the patient cohort according to sex and allocated them into two different groups based on HGS: high HGS (≥26 kg for men, n=26; ≥18 kg for women, n=35), and low HGS (<26 kg for men, n=48; <18 kg for women, n=91). The pre- and postoperative ODI, EQ-5D, and VAS scores for back and leg pain, as well as the functional mobility test results, and demographic data were compared between the two groups using independent t tests. Correlations between HGS and clinical outcome parameters were analyzed using Pearson correlation.

RESULTS

In women and men, HGS correlated with the preoperative/postoperative ODI (r₁=-0.217/r₂=-0.345 in women, and r₁=-0.384/r₂=-0.411 in men) and EQ-5D scores (r₁=0.190/r₂=0.309 in women, and r₁=0.373/r₂=0.467 in men). HGS also correlated with the four postoperative results for the functional mobility tests: alternative step test (r=-0.238 in women, r=-0.431 in men), six-meter walk test (r=-0.232 in women, r=-0.282 in men), timed up and go test (r=-0.285 in women, r=-0.359 in men), and sit-to-stand test (r=-0.238 in women, r=-0.251 in men). The preoperative and postoperative ODI and EQ-5D scores in the high HGS group were superior to those in the low HGS group. Among the four functional mobility tests, preoperative and postoperative six-meter walk test results showed improvements in the high HGS group.

CONCLUSIONS

Considering the multifactorial nature of falls, HGS may be a useful surrogate marker for predicting the risk of falls and clinical outcomes in patients with LSS.

Supplement Use in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To assess whether a standardized dietary supplementation can help to decrease postoperative muscle atrophy and/or improve rehabilitation outcomes in patients who underwent anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). MEDLINE, Scopus, and Cochrane Library databases were searched, and articles that examined protein or amino acid, vitamin, or any other type of supplementation in ACLR were reviewed. Two independent reviewers conducted the search using pertinent Boolean operations.

RESULTS

A total of 1818 articles were found after our database search. Ten studies fulfilled our inclusion criteria and only assessed patients undergoing ACLR. Four studies assessed protein-based supplementation. One study assessed creatine as a supplement. Four studies assessed vitamin-based supplementation. One study assessed testosterone supplementation. Protein and amino acid supplementation showed potential benefits; multiple authors demonstrated a combination of improved achievement of rehabilitation benchmarks, graft maturation, muscular hypertrophic response, and peak dynamic muscle strength. When we examined creatine, vitamin, or hormone-based protocols, none demonstrated results, suggesting these factors may attenuate muscle atrophy after surgery. Vitamin C and E demonstrated potentially increased local inflammation in skeletal muscle, which runs contrary to the belief that antioxidant vitamin-based supplementation may decrease the inflammatory response that plays a role in the post injury/operative period.

CONCLUSIONS

Protein-based supplementation may play a role in mitigating muscle atrophy associated with ACLR, as multiple authors demonstrated a combination of improved achievement of rehabilitation benchmarks, thigh hypertrophic response, and peak dynamic muscle strength. However, based on current literature, it is not possible to recommend a specific protein-based supplementation protocol at this time for patients undergoing ACLR. Limited evidence suggests no benefit for creatine, vitamin, or hormone-based protocols.

LEVEL OF EVIDENCE

II, a systematic review of level I-II studies.

Chronic Resistance Exercise Improves Functioning and Reduces Toll-Like Receptor Signaling in Elderly Patients With Postoperative Deconditioning

OBJECTIVE

Elderly patients continue to experience low levels of mobility during and following postoperative hospitalization that lead to persistent physical decline. Therefore, here we compared chronic resistance (CR) exercise against chronic aerobic (CA) exercise in ameliorating postoperative functioning and reducing proinflammatory muscular Toll-like receptor (TLR)-associated signaling in elderly postoperative patients.

METHODS

We conducted a prospective, randomized trial comparing the effects of 3 exercise programs (CR, CA, and CR + CA) in 66 elderly patients recovering from recent hip, femur, or pelvic fracture repair surgery. The primary outcomes were changes in anatomic/physical performance parameters (ie, maximal oxygen intake, endurance, quadriceps cross-sectional area, and maximum knee-extensor force). The secondary outcomes were changes in TLR/nuclear factor kappa beta signaling pathway marker expression.

RESULTS

Three of the 4 anatomic/physical performance parameters significantly improved for the CR and CR + CA cohorts. Muscular expression of myeloid differentiation primary response gene 88, transforming growth factor beta-activated kinase 1 (TLR signaling pathway markers), p50, p65, tumor necrosis factor α, and interleukin 6 (nuclear factor kappa beta signaling pathway markers) all showed significant reductions after CR and CR + CA. Serum expression of 2 key TLR4 ligands, heat shock protein 70 and serum amyloid A, also showed significant reductions after CR and CR + CA.

CONCLUSIONS

Three months of CR or CR + CA improves maximal oxygen consumption, quadriceps cross-sectional area, and maximum knee-extensor force while lowering muscular proinflammatory signaling markers in elderly adults with postoperative deconditioning.

Prevalence and clinical impact of sarcopenia in osteoporotic hip fracture: Single center retrospective cohort study

OBJECTIVE

The study aimed to identify the prevalence of sarcopenia in patients with osteoporotic hip fractures, investigate the anthropometric differences between sarcopenic and non-sarcopenic patients, and evaluate and compare the surgical outcomes between the two groups.

METHODS

The study included 135 patients (35 men and 100 women; mean age: 74.1 years (range; 25-96)) who received surgical treatment for hip fracture between March 2014 and October 2016 and underwent whole-body dual-energy X-ray absorptiometry (DEXA). The skeletal muscle mass index (SMI) for diagnosis of sarcopenia was measured using whole-body DEXA. The following data were collected to compare the preoperative details of the sarcopenic and non-sarcopenic groups: SMI, age, sex, type of fracture, type of operation, BMI, obesity, American society of Anesthesiologists (ASA) class, pre-injury mobility score, BMD, and follow-up period. We compared clinical outcomes, including Harris Hip Score (HSS) and the walking ability at the last follow-up visit and radiologic outcomes, including non-union and the time to union.

RESULTS

The average HHS and Parker's mobility score at the last follow-up were 81.7 and 6.9 in the sarcopenic group, and 77.6 and 6.3 in the non-sarcopenic group, respectively (p=0.149 and 0.122). Non-union was identified 0 (0%) in sarcopenic group and 4 (10%) in non-sarcopenic group (p=0.288). The mean union timer of the patients in the sarcopenia group was 4.0 months and that of patients in the non-sarcopenic group was 4.4 months (p=0.210). Multiple regression analysis did not show any significant association between sarcopenia and postoperative surgical outcomes, including HHS, mobility score at the last follow up, non-union, and time to union.

CONCLUSION

Although the present study showed that the prevalence of sarcopenia in hip fracture patients was 45.9% (62/135), there was no clinical association between sarcopenia and postoperative. Based on these results, the clinical impact of sarcopenia may be confined to increased risk of hip fracture occurrence and surgical outcomes of hip fracture may not be affected by sarcopenia.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Prevalence of sarcopenic obesity in adults with end-stage knee osteoarthritis

OBJECTIVE

To identify the prevalence of sarcopenic obesity, a phenotype of low muscle mass and high adiposity, in adults with end-stage knee osteoarthritis (OA). Various diagnostic criteria, including assessment of muscle/fat mass, muscle strength and physical function, were used to identify patients with and without sarcopenic obesity, and to compare outcomes of pain, function and quality of life.

DESIGN

Cross-sectional clinical study including adults with a body mass index (BMI) ≥30 kg/m² and knee OA. Body composition was measured by dual-energy X-ray absorptiometry (DXA). Assessments included gait speed, handgrip strength, six minute walk test, and self-reported pain, physical function, and health-related quality of life using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol Foundation (EQ-5D).

RESULTS

151 adults (59% female) aged 65.1 ± 7.9 years, mean BMI 37.1 ± 5.5 kg/m², were included. Prevalence of sarcopenic obesity using diagnostic cut-offs of appendicular skeletal muscle mass (ASM) relevant to height², weight and BMI varied from 1.3% (95% confidence interval (CI): 0.2-4.7%) to 14.6% (9.4-21.2%) and 27.2% (20.2-35%), respectively. A combined diagnostic approach including low ASM with either low strength or low function yielded a prevalence of 8.6% (4.7-14.3%). Sarcopenic obesity influenced walking speed, endurance, strength, and patient-reported difficulty with self-care activities, regardless of diagnostic approach.

CONCLUSION

Prevalence of sarcopenic obesity varied depending on diagnostic criteria. Given the impact of this condition and OA on physical function, we suggest a combined diagnostic approach be used to clarify expected prevalence and enable early clinical identification and management of sarcopenic obesity in patients with knee OA.

Obesity may be a risk factor for recurrent heterotopic ossification in post-traumatic stiff elbow among children and teenagers

BACKGROUND

Post-traumatic elbow stiffness and heterotopic ossification (HO) affects long-term life quality, as commonly in children and teenagers as in grownups. Childhood obesity considerably influences public health because it causes stroke, hypertension and diabetes mellitus. Previous research discussed its clinical complications in orthopedic diseases. However, no clinical research reveals the interaction between childhood obesity and HO after elbow injuries.

HYPOTHESIS

Obesity might be a risk factor of recurrent HO after elbow arthrolysis in children and teenagers, correlated with the severity of postoperative HO.

METHODS

Fifty seven post-traumatic children and teenagers undergoing elbow arthrolysis were retrospectively reviewed and divided into underweight/normal-weight group (n=28) and overweight/obese group (n=29) according to the gender-specific body mass index (BMI)-for-age growth chart. The Hastings and Graham classification was used to evaluate HO recurrence. We also assessed Mayo elbow performance scores and range of motion.

RESULTS

The mean age, gender, pathogenesis, side of injury, time of injury, follow-up duration were analyzed. Overweight/obese children and teenagers were more likely to develop recurrent HO (p=0.005) than underweight/normal-weight children and teenagers. A significant difference in the severity of recurrent HO between two groups was confirmed (p=0.028). The range of motion was improved greatly in underweight/normal-weight group compared with that in overweight/obese group (p=0.001).

CONCLUSIONS

The HO recurrence difference between two groups confirmed the hypothesis. Although underlying mechanisms are unclear, weight control might promote postoperative and long-term rehabilitation of the elbow joint for children and teenagers.

LEVEL OF EVIDENCE

III, retrospective cohort study, treatment study.

Sarcopenia as a Risk Factor for Prosthetic Infection After Total Hip or Knee Arthroplasty

BACKGROUND

Sarcopenia, an age-related loss of muscle mass and function, has been previously linked to an increased risk of morbidity, mortality, and infection after a variety of surgical procedures. This study is the first to evaluate the impact of the psoas-lumbar vertebral index (PLVI), a validated marker for central sarcopenia, on determining post-arthroplasty infection status.

METHODS

This is a case-control, retrospective review of 30 patients with prosthetic joint infection (PJI) diagnosed by the Musculoskeletal Infection Society criteria compared to 69 control patients who underwent a total hip or knee arthroplasty. All patients had a recent computed tomography scan of the abdomen/pelvis to calculate the PLVI. PLVI was evaluated alongside age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, and smoking status to determine the predictive value for infection.

RESULTS

Notably, the infected group had a large, significant difference in their average PLVI (0.736 vs 0.963, P < .001). The patient's PLVI was a predictor of infection status, with a higher PLVI being protective against infection (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.109-0.715, P = .008). Additional predictors of infection status were higher American Society of Anesthesiologists score (OR 10.634, 95% CI 3.112-36.345, P < .001) and Charlson Comorbidity Index (OR 1.438, 95% CI 1.155-1.791, P = .001). Multivariate, binary logistic regression analysis confirmed that PLVI was a significant independent predictor of infection status (B = -0.685, P = .039).

CONCLUSION

PLVI, a marker for central sarcopenia, was demonstrated to be a risk factor for PJI. Further research and consideration of sarcopenia as a screening and optimizable risk factor for total joint arthroplasty must be explored.

The impact of sarcopenic obesity on knee and hip osteoarthritis: a scoping review

BACKGROUND

The progressive, debilitating nature of knee and hip osteoarthritis can result in severe, persistent pain and disability, potentially leading to a need for total joint arthroplasty (TJA) in end-stage osteoarthritis. TJA in adults with obesity is associated with increased surgical risk and prolonged recovery, yet classifying obesity only using body mass index (BMI) precludes distinction of obesity phenotypes and their impact on surgical risk and recovery. The sarcopenic obesity phenotype, characterized by high adiposity and low skeletal muscle mass, is associated with higher infection rates, poorer function, and slower recovery after surgery in other clinical populations, but not thoroughly investigated in osteoarthritis. The rising prevalence and impact of this phenotype demands further attention in osteoarthritis treatment models of care, particularly as osteoarthritis-related pain, disability, and current treatment practices may inadvertently be influencing its development.

METHODS

A scoping review was used to examine the extent of evidence of sarcopenic obesity in adults with hip or knee osteoarthritis. Medline, CINAHL, Web of Science and EMBASE were systematically searched from inception to December 2017 with keywords and subject headings related to obesity, sarcopenia and osteoarthritis.

RESULTS

Eleven studies met inclusion criteria, with indications that muscle weakness, low skeletal muscle mass or sarcopenia are present alongside obesity in this population, potentially impacting therapeutic outcomes, and TJA surgical risk and recovery.

CONCLUSIONS

Consideration of sarcopenic obesity should be included in osteoarthritis patient assessments.

Association between obesity with low muscle mass and dialysis mortality

BACKGROUND/AIM

To examine the association between body composition and dialysis mortality.

METHODS

Adult patients who underwent haemodialysis in Taoyuan General Hospital from 2012 to 2016 were enrolled. We reviewed their baseline characteristics and followed up their treatment over 5 years after dialysis. Patients with body mass index >25 kg/m² were defined as obese. High or low muscle mass were classified by skeletal muscle mass index (SMMI) based on consensus from Chinese population. All age-matched subjects were classified into four groups: (A) optimal; (B) obesity; (C) low muscle mass; and (D) obesity with low muscle mass. Adjusted hazard ratios for mortality and cumulative survival curves were evaluated by Cox proportional hazard model and Kaplan-Meier method. The discriminative power of SMMI was calculated according to the area under the curve and the receiver operating characteristic curve.

RESULTS

From a total of 176 age-matched patients, the incidence rates of mortality for different groups were 3.7, 7.8, 10.3 and 16.5 per 1000 person-months. After adjusting for continuous variables, SMMI was independently associated with mortality. The difference between groups A and D was more significant in women than in men after multivariate adjustment (adjusted hazard ratios: 7.465 vs 1.682) (P = 0.035 and 0.553). The discriminative power of SMMI to predict 5-year mortality was 0.700 for men and 0.750 for women, and the best cut-off values were 11.1 and 8.4 kg/m² CONCLUSIONS: Low muscle mass was associated with dialysis mortality. Obesity with low muscle mass was a predictor for dialysis mortality in women.

A pilot study examining the impact of exercise training on skeletal muscle genes related to the TLR signaling pathway in older adults following hip fracture recovery

Older adults after hip fracture surgery experience progressive muscle atrophy and weakness, limiting full recovery. Further understanding of the molecular mechanisms in muscle with adaptation to exercise training in this vulnerable population is necessary. Therefore, we conducted a pilot study to investigate the skeletal muscle inflammatory and ceramide biosynthesis gene expression levels associated with the toll-like receptor (TLR) pathway before (Pre) and following a 3-mo multicomponent exercise training program in older adults (3M, 4F; 78.4 ± 13.3 yr; 25.5 ± 2.3 kg/m²) ~4 mo after repair from hip fracture (HipFx). Vastus lateralis biopsies from the surgical limb were obtained before (Pre) and after training. Molecular end points and muscle function data were also compared with matched nonexercise healthy controls (CON). As a follow-up analysis, we evaluated specific sphingolipid pools in HipFx and CON muscle. Following training, quadriceps cross-sectional area, strength, and 6-min walk (6MW) increased in the surgical limb (P < 0.05). Additionally, MYD88, TAK1, NFKB1, IL6, SPT2, and CERS1 gene expression decreased after training (P ≤ 0.05), but some remained elevated above CON levels. Interestingly, MYD88 mRNA was inversely correlated to quadriceps CSA, strength, and 6MW. Finally, muscle dihydroceramides and phosphoceramides in HipFx were lower than CON at Pre (P ≤ 0.05), but after training differences from CON were removed. Together, our pilot data support that exercise training alters skeletal muscle inflammation and ceramide metabolism associated with TLR signaling in older adults recovering from hip fracture surgery and may be related to improvements in muscle function recovery.

NEW & NOTEWORTHY

These pilot data demonstrate that 3 mo of exercise training in older adults recovering from hip fracture surgery was able to mitigate skeletal muscle gene expression related to inflammation and ceramide metabolism while also improving surgical limb lean tissue, strength, and physical function.